CLIENT INFORMATION
Child’s name: / Gender: / M F / Date of birth: / Age:Address: / Email(s):
Telephone (H): / Telephone (W): / Mobile:
NDIS (if relevant) / NDIS number:
Permission to contact NDIS? Yes, No. / Start date:
End date: / OT supports? Yes No
Speech pathology supports? Yes No
FAMILY
Parent(s)/Caregiver(s): / Brothers/sisters (incl. age):Family history of communication and/or learning difficulties? / Yes No / Speech/language, Stuttering, Autism, Dyslexia, Behaviour, Chromosomal,Motor, Sensory, ADHD, ODD, Other:
Additional info/explanation:
SCHOOL
School/Preschool/Day Care: / Days: / Mon, Tue, Wed, Thu, Fri. / Grade/Class:Teacher’s Name: / Email: / Phone:
Teacher concerns: / Permission to contact school to discuss: / Yes No
PREGNANCY/INFANCY/EARLY CHILDHOOD
Any complications with pregnancy/birth? / Yes No / Info:Delivery: / Vaginal, C-section, Breach. / Term: / Full term, Overdue – weeks, Premature – weeks.
Any issues with feeding, sleeping, or toileting? / Yes No / Info:
Babbled? / Yes No / When? / months. / Sit up? / Yes No / When? / months.
First words? / Yes No / When? / months. / Crawling? / Yes No / When? / months.
Combining words? / Yes No / When? / months. / Walking? / Yes No / When? / months.
SOCIAL/EMOTIONAL SKILLS– which of the following apply?
Temper tantrums, Easily frustrated, Impulsive, Dislikes change, Perfectionist, Separation difficulties, Anxious,Sensitive, Quiet, Difficulty sharing/taking turns, Difficulties being flexible with rules, Overly affectionate, Difficulty making friends, Difficulty making eye contact, Socially immature, Prefers to play alone, Difficulties understanding other’s emotions.
SELF-CARE SKILLS– which of the following apply?
Toilets independently, Dress independently, Do up button’s independently, Tie shoelaces,Use cutlery independently - Knife, Fork, Spoon.
Sleeps well? / Yes, No. / Falls asleep and stays asleep, Self-soothes if wakes, Sleeps with light on,
Sleeps in room independently, Shares a room with someone -
Any sleep support(s)?: / Medication: No, Yes - / Weighted items: No, Yes - / Other:
MEDICAL
Medical condition(s) (if any)? / Diagnosing professional:Medication (if any): / Allergies (if any):
Has your child had: / Ear infection(s), Asthma/respiratory, Head injury, Constipation/diarrhoea, Hyperactivity, Sleep issues, Heart condition, Mental health, Other:
Additional info/explanation:
SERVICES INVOLVED (previous and/or current professionals involved – assessments, therapy, support, etc.)
Professional / Yes / No / Name / Organisation / Reason involved / Date/duration / Current?Speech Pathologist / Yes/ No
Occupational Therapist / Yes/ No
Psychologist/Counsellor / Yes/ No
Paediatrician / Yes/ No
Ear Nose and Throat Specialist / Yes/ No
Audiologist (hearing tests) / Yes/ No
Optometrist / Yes/ No
Other / Yes/ No
How often are you seeing above professionals + goals?:
HEARING
Hearing assessment? / Yes No / When? / Company/professional:Hearing assessment result: / Normal, Other: / Grommets: date: / Other info:
VISION
Vision assessment? / Yes No / When? / Company/professional:Vision assessment result: / Glasses?date: / Other info:
GENERAL
Who referred you to ABEI?
Name: / Relationship: / Reason:Please describe your child’s communication, behaviour, and social interactions:
Please describe/list your child’s interests/hobbies/favourite activities and toys:
What are your main concerns?:
In the last 6 months, what is the area in which your child has made the most progress?:
In the last 6 months, what is the area in which your child has made the least progress?:
What would you like to achieve from the visits with your Therapist(s)? – i.e. what are your goals for your child’s development?:
Is there anything else you would like to share with the Therapist to better understand your child?:
How did you find out about Above and Beyond Early Intervention (ABEI)?:
INVOICES – to be sent to:
Name: / Organisation (if relevant): / Email:- Please pass on copies of any documentation, such as letters and reports, to ABEI () in support of any diagnoses and services provided by other professionals involved in the care and management of your child.
- Please pass on a copy of your child’s NDIS plan (if relevant).
PRIVACY AGREEMENT
- I authoriseABEI to release information (including reports) to the client’s Doctor(s), health agencies, government agencies, NDIS (if relevant), insurance companies and/or professional consultant, other health professionals, school/Teachers, and family.
- I certify that the information on this client information form is correct to the best of my knowledge.
- I authorise ABEI to contact other professionals involved to discuss client and obtain relevant information (including reports) from these professionals.
PARENT/CAREGIVER SIGNATURE: / DATE:
FINANCIAL AGREEMENT
- I authorise the treatment of the named client and agree to pay all fees and charges for such treatment before or at the time of the session unless otherwise arranged and confirmed in writing.
- If an NDIS Participant: I authorise ABEI to create service bookings and make claims for all scheduled appointments/services provided as per our verbal agreement and/or service agreement document. In the case that NDIS funding is not available to pay for sessions provided, I will privately pay for outstanding invoices for services provided within this agreement. If any changes regarding NDIS plan occur (e.g. funding changes, plan date changes, funding ceasing, new funding awarded, plan detail/support changes) I will notify ABEI immediately as this may affect billing for services.
PARENT/CAREGIVER SIGNATURE: / DATE:
ACCEPTANCE OF POLICIES AND PROCEDURES
- I have read and understood ABEI’s policies and procedures, which includes costs and general service information.
- All of my questions regarding the policies and procedures have been answered/addressed by ABEI.
PARENT/CAREGIVER SIGNATURE: / DATE:
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